With AEP right around the corner we think it would be a great time for you to familiarize yourself with the companies that you are appointed with. By doing so, you have all the knowledge you need to give potential clients.

Need some help finding your carrier website? Type the carrier name in the search bar of your preferred internet search engine and the carrier you are looking for should pop up on the top of your search.

With that being said, we have another great reference for you to use:

That’s right. Agent Pit Stop. Did you know that on our webpage you can:
Click on the CLIENTS tab to see all your clients, plus you can see all upcoming birthdays. Making it easy for you to give them a phone call, send a card, or let them know of plans that may be more suitable to their health needs.

Under the CONTRACTS tab you can see which documents we have on file and when they are expiring, plus you can request contracting information for carriers you may not be appointed with.

The RATES tab has a search engine for you to use to better prepare you for your appointments. It helps your clients know the most updated rates that are available.

The BILLING tab will show any balances you have with Van Berg.

The COMMISSION STATEMENTS tab will show you exactly that. What date you were paid, the company/companies, and a file to download of the statement for that date.

The SECURE EMAIL tab is for those who would like to sign up or log in to their secure email page.

Last, but not least, the BLOG tab. Keep up to date with information about carriers, helpful tips, changes in insurance, and other information that may be pertain to the business.

As always, if you cannot find what you are looking for here and still need additional help, we have several people in the office to help point you in the right direction. Please do not hesitate to call us at (800) 723-5228.

One of the most common questions an agent has to answer is “when can I enroll?” Because there are a wide variety of situations, CMS has created a handy chart to help you determine the options available to a client.

As tensions mount over physician reimbursement rates and health systems and insurance carriers seek ways to improve performance to secure higher payments for themselves, more health systems are looking to the unique solution of becoming an insurance carrier in their own right. A number of large regional health systems like Sutter Health and Stanford Health Care have ventured into the individual health and Medicare Advantage markets, and others seem poised to follow suit. So why do health systems want to take on this challenge?

More control means higher star ratings – Star ratings issued by CMS have been an important measure of plan quality and performance for several years, and the expansion of the program to include hospitals and long term care facilities shows that the ratings are here to stay. Star ratings aren’t just a feather in the cap, they afford special privileges like the ability to accept new members outside of the normal enrollment periods and higher reimbursement rates. The success of Kaiser’s Senior Advantage products has proven that having control of the entire process – including providers, pharmacies, and hospitals – is one of the best ways to ensure the kind of efficiency and well-coordinated care that leads to five star ratings. Other large health systems that already have the provider and hospital infrastructure want to leverage their own networks to achieve similar results.

Patients want stable networks – One of the most frequent complaints from consumers is that their carrier’s network changes from year to year, and they have no choice but to change carriers to follow their doctor. Network stability is in fact a frequent topic in discussions of Medicare Advantage reform and regulation. Large health systems who already have affiliated doctors likely see lower turnover rates amongst their providers and can remove some of that stress for their patients, especially in the wake of high profile contract disputes like the protracted negotiations between Sutter Health and Blue Shield.

Patients have relationships with their doctors, not their insurance carrier – As long as claims get paid, very often clients simply want the plan that allows them to see the doctors they’re used to. The providers and health systems that patients use have often had years to build trust, while patients may only interact with their insurance carrier when there’s a problem with a claim being paid or with getting approval for care they need. Some established insurance carriers are beginning to do more client outreach in an effort to change this, but the advantage is still strongly on the side of the doctors and hospitals that people already know and trust.

Increased efficiency means better care and higher profits – The ability to streamline patient care, as well as billing and claims, gets patients the care they need faster and more easily. It can also save money by eliminating unnecessary or redundant procedures and cutting back on the number of steps and man hours it takes to file and process a claim.

While becoming a carrier as well as a health system is a daunting task, it’s a trend on the rise for the simple reason that, if done well, it can lead to better, more efficient care and higher profits.

Medicare Advantage plans saw continued growth over the past year, doing little to change the common notion that managed care will become ever more popular among Medicare beneficiaries. The total number of enrolled beneficiaries increased from 32% of 54 million eligibles this time last year to 33% of 55 million eligibles this year.

Almost all insurers saw growth:
– Total enrollment leader UHC saw a 10.5% increase
– Six of nine other companies with more than 250,000 members saw growth
– Cigna had the largest percentage increase at 13.6%
– Large insurers saw an overall average growth of 5.2%, while small insurers saw an average growth of 5.6%

While UHC and Humana continue to dominate with a combined market share of 38.5%, the fact that smaller insurers saw overall growth similar to the larger insurers is an indicator that the market is sustainable even outside the huge market share of the largest companies. Smaller, more regional carriers are surviving and even thriving.

Selling Medicare Advantage plans does mean extra work with certifications and abiding by CMS regulations, but the increasing market share makes it worth the time and effort. If you haven’t already, get a few MA carriers in your bag and be prepared to offer your clients what a growing number of them may want.

Applications being rejected or kicked back can be frustrating and time consuming. You are not only setting aside time to figure out what plan works best for the client but to also meet with them and help fill out the application as needed. Don’t let your time or your client’s time be wasted because of little mistakes that could have been prevented by taking an extra minute to check over your work.

Be Thorough â€“ One of the biggest hold ups with processing can be that you’re missing the most basic information on an app. As an agent you are responsible for obtaining information such as a client’s name, phone number, address and Medicare ID and these are very important bits of info. However when you get into the groove of writing apps, especially in group settings or during the annual election period where the process comes at a faster pace, you may move right past a question without answering it. Always scrub your own app before submitting to check for these easy to fill questions.

Make sure the plan selected actually works for your client â€“ Sometimes a simple mistake of choosing the wrong plan can create a kickback. For instance Blue Shield of California only partially covers Contra Costa County and Care1st has a partial county in Alameda County. Knowing a plans coverage area and double checking zip codes is key to making sure you’re selecting the right plan for your client in situations such as those

Other possible snags to watch out for are making sure you’ve selected the correct special election period (SEP), whether or not your client is dual eligible, or choosing a plan that helps with a specific health issue such as diabetes or a heart condition.

Provide the Right Paper Work â€“ At various times extra paper work is needed along with the client’s application. Think ahead and predict what documentation could be needed. For instance, in California, Medicare supplements being written on the birthday rule almost always require proof of prior plan. Having a copy of the client’s previous policy ID card and submitting it with the application could save you time from needing to do so later, while the application sits on hold. When writing an application that has an SEP it’s also very important to include the correct information on why it’s an SEP. If the client has recently moved to a new zip code or state where their plan no longer exists then include a letter from their policy’s provider showing they have moved out of the network.

Paper work showing Power of Attorney (POA) is particularly important to point out because many agents often forget about including documentation for POA since it doesn’t frequently come up. Although there are a few companies that don’t require documentation, the majority of companies do, which is why it’s a good policy just to always include POA documentation.

Don’t Dawdle with Corrections â€“ If you do have an issue with an application (like you wrote down the Medicare ID incorrectly or have missing paper work, etc.) make sure to get it to the company ASAP. Providers offer a time frame to get corrections in before they reject applications. Once you miss a deadline it is rare that the company will open that application back up again. This leaves you either having to write an entirely new app if the election period is still open or, worst case scenario, it can leave your client without coverage.

During the weeks before Annual Election Period there is a spike in the number of agents contracting with new carriers. But why wait until the busiest time of the year to contract? Why not have the tools you need to insure you’re prepared for each client all year round? Here are just a few reasons to contract now:

Be Proficient â€“ First off, ask yourself if you are currently confident with all of the products you have to offer a client. Are you prepared if you receive a call from a referral that is in a neighboring town outside your usual area? Don’t be caught without the most competitive plans in not only your direct area, but surrounding areas as well. The most competitive plan in one zip code can be drastically different in the next. When you’re missing something from your “tool bag,” clients can become uneasy about your ability to write the policy that best fits their needs. You might also miss out on referrals that could otherwise help grow your book of business.

Be Prepared â€“ Having the right materials and information for a company can be crucial to making the right sale. Applications and promotional materials can take a while to arrive. The same goes for properly registering sales events and advertising materials. Contracting early allows you to have these supplies sooner and on hand when needed.

Stop Losing Sales â€“ Clients often hear of health insurance plans from commercials or through their friends and they’re suddenly set on having that specific product. No other product will do in their minds. This happens more and more often. Advertising is effective and friend’s opinions matter. Just because you personally think that another plan might be better doesn’t mean your client will be set on that product. Offering more options opens up more opportunities.

Don’t Scramble â€“ Clients need to feel like you have a handle on their insurance needs. Waiting until a client requests a company and then starting the contracting process is an easy way to lose a client. Especially if they’re a new client and don’t have long until their enrollment period ends. You don’t want to have to refer your client to another agent and lose a potential sale.

Know Your Contract â€“ While keeping everything else listed above in mind, it’s also important to know your limitations or if it’s time to rework your contracts. Know the difference between being a captive agent, career agent and a broker and contract in the way that makes the most sense to you. Captive agents can only sell the products from the company they are employed by, while a career agent can offer other products but only after first offering the products from the company they work with. Brokers, on the other hand, are not chained down. They are able to sell any product that they are successfully appointed and certified with, ensuring they have a wide range of products to cover their client’s needs including unexpected referrals.

We know that Medicare Advantage plans can often be less expensive month to month, but is it possible that they can also lead to better health?

A few reasons why Medicare Advantage plans may actually lead to healthier clients.

Help catch problems early – MAPD plans with robust claims and records tracking systems can help make sure that a member is receiving the routine preventive care and follow-up visits that they need. Many also offer wellness programs for things like starting an exercise program or quitting smoking, that can help curb common health problems like high blood pressure and high cholesterol.

Coordinate care between different providers – A designated primary care physician handling specialist referrals can mean a member’s doctors has a better understanding of their overall health and to better coordinated treatment plans.Â Medication Therapy Management (MTM) programs offered by plans can also help make sure that prescriptions written by different doctors are working together, and work with doctors when adjustments may be warranted.

Cut back on repeated or unnecessary tests and procedures – No one likes to go in for blood work, MRIs, or other diagnostic tests. Medicare Advantage plans can help keep track of tests ordered by various doctors and save clients time and money by preventing duplicate procedures, or procedures that may not be necessary in light of their overall health.

Get better outcomes at a lower cost – Appropriately coordinated care can save members money in copays and help keep premiums affordable for everyone. Most importantly, getting the right care at the right time can result in healthier members!

Medicare Advantage plans won’t be the right option for every client and it’s important to offer the appropriate plan, whether it’s a Medicare Advantage plan or a Medicare Supplement. However, it’s important to consider the potential benefits of coordinated care through a Medicare Advantage plan, and not just the lower cost.

The first thing many clients ask when presented with a new plan is “can I keep my doctor?” It’s an easy enough question to answer with a quick search in a provider directory or a quick call to member services, but there can be more to it than a simple yes or no.

Here are some things about provider networks your clients need to be aware of before they choose a plan.

Networks can change at any time – Providers can drop their contract with a plan essentially whenever they want. A provider who is in network when the plan year starts or when a client becomes Medicare eligible won’t necessarily still be in network even just months or weeks in the future.

Different plans from the same carrier can have different networks – Some carriers have certain plans with lower costs or more robust benefits than their other plans. In exchange, these plans have smaller networks. It’s not enough to know that a provider works with a certain carrier, you also have to be sure that they’re in network for the specific plan in question.

Every doctor in a practice may not be in network for a certain plan and carrier – In most cases, an entire practice or medical group will be contracted together with a particular carrier. However, there are times when this may not be true, depending on how the business side of the practice is run. It’s a good idea to double check on each provider individually, even if it’s providers who share an office.

They may have a Special Election Period if their doctor leaves the network – If a carrier makes significant changes to their network, CMS may determine that affected members are eligible for a one time SEP to move to a different MAPD. In California, they’re also likely eligible for guaranteed issue into a Medicare Supplement plan in accordance with the Knox-Keene Act, with certain restrictions.

They may have continuity of care allowances – Some carriers will allow a grace period during which they’ll allow their members to see providers who have left the network while they transition to a new provider. This is typically limited to members who are considered in active treatment, and the timeframe can vary.

Making sure clients understand the ins and outs of their plan’s network will help them get the care they need and help you keep a happy client.

People typically don’t like feeling like they’re being sold on something, especially when it comes to something as important as their health insurance. If you give your clients the information they need, they can make their health care decisions with confidence and without you ever needing to give them a sales pitch.

Here are some things to remember to make your presentations more educational.

Clients will feel most comfortable if they really understand their plan. – Whatever plan a client chooses, they’ll be happiest if they know what to expect in terms of copays, premiums, deductibles, networks, and added benefits. Disappointment and frustration can set in when a client expects something to cost a certain amount of work a certain way and it doesn’t.

Clients want to feel like you respect their intelligence. – You may be the expert on insurance, but clients want to be spoken to as intelligent adults and not talked down to. Even if they need the absolute basics explained, treat them with respect and give them the information they need in a way they can understand.

Explain what they need to know instead of showing off what you know. – All the interesting, complex things you know don’t matter. What matters is that clients get the information that they need. Resist the urge to use unnecessary jargon and go off on tangets. Explain the terminology they do need to know and don’t waste your client’s time with excessive information.

If you approach client meetings less as elaborate sales presentations and more as conversations with someone you care about, all of this will come naturally, leaving your clients well-informed and confident.

Balance billing, in which a provider bills a member for the difference between what their carrier will pay for a service and that provider’s “retail” rate, is a relatively common practice in the medical industry and is allowable in certain circumstances for people enrolled in some types of individual and family plans. For Medicare beneficiaries enrolled in Medicare Advantage plans, however, the practice is explicitly forbidden by CMS except in a very narrow set of circumstances.

With any Medicare Advantage HMO or PPO, including Point of Service HMOs and Regional PPOs, members are protected from paying more than their agreed upon cost sharing for any covered services. These kinds of patient protections are a key part of the Medicare system, and are agreed to by all providers who choose to treat Medicare beneficiaries, including non-contracted providers who agree to accept assignment on a case by case basis. While in some cases balance billing to the plan may be allowed, that should be handled between the provider and the plan and not involve the member. Unfortunately, if claims are processed incorrectly due to confusion or misinformation at a provider’s office, members may still end up billed for services for which, by law, they should not be liable. In the case of any confusion, members should be guided by the Explanation of Benefits provided to them by their carrier above bills sent to them by providers. It is not unusual to see a provider bill a patient before the claim has been processed and paid by the carrier, resulting in an incorrect amount shown due.

It’s important to note that the restrictions on balance billing apply only to members in Medicare Advantage plans, and only to services covered by their MA plan and by Original Medicare. Members in Medicare Advantage plans that do not cover out-of-network providers, members seeking services that are outside the scope of their coverage (even through a Medicare participating provider), members who see providers who have opted out of Medicare entirely and are not contracted with their plan, and members with Medicare Supplement plans would all be subject to different charges and afforded different protections.

As their agent, you are the first point of contact for questions or problems for many clients, so if a Medicare Advantage client calls you asking about a bill they received, refer to the following.

If they saw a plan contracted provider – There is no balance billing paid by either the plan or the member. Member is responsible only for their share of cost as determined by their plan.

If they saw a non-plan contracted, Original Medicare participating provider – There is no balance billing paid by either the plan or the member. Member is responsible only for their share of cost as determined by their plan, which may be higher than their share of cost when seeing a plan contracted provider. This situation applies only to members in plans with out-of-network benefits and does not apply to members in HMOs that do not cover out-of-network providers outside of emergencies.

If they saw a non-plan contracted, non-Original Medicare participating provider – The Medicare Advantage plan may owe the provider the difference between the Medicare limiting charge and the member’s cost-sharing, but the member is only liable for their standard copay amount or their standard coinsurance percentage calculated using the Medicare limiting charge, not any higher amount billed to the plan by the provider. As in the above example, this only applies to members in plans with out-of-network benefits. For example, if a Medicare Advantage PPO member sees an out-of-network, non-participating provider, and the member has a 20% co-insurance for seeing out-of-network providers, that member would be liable for no more than 20% of the Medicare limiting charge, which is 109.25% of the Medicare fee schedule rate. The provider may bill the plan for any additional amount, but that should not involve the member.

While members are of course still liable for their cost-sharing, including out-of-network charges, it’s important for agents to be aware of the potential for mistakes and to be able to help answer questions or reassure clients who may have concerns about billing, despite it being the primary responsibility of the carrier. After all, this is a service business, and even just a few pieces of information and the right phone number to call can make a client feel well taken care of, and that should always be the goal.